Confidentiality Release

In accordance with the privacy rule of the Health Insurance Portability Accountability Act of 1996 (HIPAA), Nicole Reginelli Birth Services requires a signed release form from you, the client, before taking any notes about you or your birth or postpartum support experiences.

You, the client, should keep a copy of this signed form (emailed to you after signing) for your records. Nicole Reginelli Birth Services keeps the signed original in compliance with HIPAA regulations.

Confidentiality of medical and personal information obtained during the course of the doula’s work is of the utmost importance to Nicole.

Although every precaution is made to keep notes, emails, and texts private, Nicole Reginelli Birth Services does not use HIPPA compliant communication software for client notes, texts, or emails.

— I hereby give permission for Nicole Reginelli to take notes about me, including personal information I choose to disclose to her, and information regarding my labor, birth and postpartum, as well as any information regarding my child/ren. I understand that this information will be shared with Nicole’s back up doula as needed.

— I hereby give permission for Nicole Reginelli to use text and email to communicate with me throughout the course of my relationship with her and her backup team. I understand that notes may be taken analog or digitally. I understand the privacy limitations of using these mediums to communicate with my doula and her backup team.